resuscitating the hypotensive patient
DESCRIPTION
A presentation for Emergency Nurses on Resuscitating Hypotensive Patients!TRANSCRIPT
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Resuscitating the Hypotensive
Patient Kane Guthrie FCENA
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Hypotensive Resuscitation
•Look at shock
•Fluid resuscitation
•Pharmacology of vasoactive medications
•Current evidence
•Case Studies
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Shock
Inadequate oxygen
delivery to meet tissue demands
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Shock is a
time-dependantdisorder!
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Epidemiology of Shock
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Diagnosing Shock
3 components
•Systemic arterial hypotension
•Clinical signs tissue hypoperfusion
•Hyperlactatemia
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Hypotension is Bad
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Hypotension in ED
•Independently predicts in-hospital mortality
•Risk of death increases:
•SBP <80mmHg
•Sustained hypotension >60min
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Hypotension Predicts Mortality
•Pulmonary Embolism
•Myocardial Infarction
•Traumatic Brain Injury
•Sepsis
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Assessing the Shocked Patient
• Physical exam can assess overall tissue perfusion:
• Assess mental status
• Are patients confused?, dizzy?, drowsy?
• Assess skin
• Is the skin cool or mottled?
• Assess kidney perfusion
• Is urine output less than 0.5 mL/kg/hour?
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Laboratory Assessment
• Laboratory testing can be used to assess perfusion:
• Elevated serum creatinine
• This signifies reduced organ perfusion
• Elevated liver function tests
• This signifies reduced organ perfusion
• Oxygen saturation of venous blood
• SVO2
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Checking Lactate
•Marker end organ perfusion
•End product – anaerobic metabolism
•Lactate >4 = panic value
•Lactate normalisation
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Using CVP
•Poor evidence behind recommendations
•8-12mmHg is ideal range
•>15 mmHg if ventilated
•<8mmHg & hypotensive = fluids
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Measuring IVC
Full non-collapsing IVC = Pt adequately filled.
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Fill the Tank
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Fluid Resuscitation
•Improve microvascular blood flow
•Increase cardiac output
•May benefit cardiogenic shock
•Fluid maldistribution
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What fluid & How Much?
•Crystalloid –first choice
•Albumin in certain patients!
•Boluses 500ml-1tre every 20-30mins
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Monitoring Fluid Resuscitation
•^ systemic arterial pressure
•< heart rate
•^ urine output
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When Fluids Fail
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Vasoactive Agents
•Used to optimise:
•End-organ perfusion
•Oxygen delivery
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Inotrope(s)
•Increase the force & velocity of myocardial contraction with increased contraction, stroke volume & cardiac output.
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Inotropes
•Examples:
•Adrenaline
•Dobutamine
•Isoprenaline
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Vasopressor(s)
•Increase vascular tone with raised MAP & SVR.
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Vasopressor(s)
•Noradrenaline
•Vasopressin
•Dopamine
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Push Dose Pressor
•Short acting vasopressor that works through potent & selective alpha stimulation.
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Push Dose Pressor
•Metaraminol
•Adrenaline
•Ephedrine
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The Hard Evidence!
•No agent has shown to have superiority over any others in good quality studies!
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Use Based On
•Cost
•Availability
•Interpretation of physiology
•Personal/physician preference
•Institutional preference
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Target Receptors
•Alpha 1- vasoconstriction, ^ SVR
•Alpha 2 – smooth muscle contraction
•Beta 1 – positive chronotrope/inotrope, ^HR, ^contractility
•Beta 2 – induce vasodilatation
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CVC
•Preferred
•IVC till bridge to CVC
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Do We Always Need CVC?
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Indications
•Fluid resuscitation = failed
•Persistent hypotension
•Improve contractility & cardiac output
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Invasive Monitoring
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Forget BP –Focus MAP
•Mean arterial pressure
MAP = CO x SVR
•Target MAP >65mmHg
•Chronic hypertension aim higher
•Measure adequate tissue perfusion
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Case 1
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Case 1
•What vasoactive medication is indicated?
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Adrenaline
•Alpha & beta adrenergic properties
•Treats 3 aspects of anaphylaxis
•Laryngeal oedema
•Bronchospasm
•Shock
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Adrenaline Actions
•Vasoconstriction
•Reduction - mucosal oedema
•Bronchodilation
•Increased myocardial contractility
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Case 1
•What dose and route would you give it?
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Case 1
•Adult 0.3-0.5mg (1mg/ml)
•IMI (lateral thigh)
•Rpt as needed - consider infusion.
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Case 2
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Case 2
•What vasoactive medication is indicated?
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Noradrenaline
•Surviving Sepsis Guidelines 2013
•Norad = vasoconstriction - HR + contractility.
•6mg 100mls or 3mg 50mls 5% Dextrose
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Vasoactive's in Sepsis
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Case 3
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Postintubation Hypotension
•Occurs in 23% of ED intubations
•Vasodilation of induction agents
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Case 3
•What vasoactive medication is indicated?
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Push Dose Pressors
•Metaraminol 10mg/ml (mix in 20mls)
•Sympathomimetic amine
• increases systolic/diastolic BP
•Short acting 3-10min
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Case 4
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Cardiogenic Shock
•Results from primary cardiac dysfunction
•MI
•papillary muscle/ventricular septal rupture, left ventricle dysfunction
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Case 4
•What vasoactive medication is indicated?
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Inotropes
•Dobutamine
•Beta 1 effects - cardiac contractility
•Beta 2 effects - reduce afterload
•Refractory consider adding Noradrenaline
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Take Home Points
•Shock/hypotension is common
•Fluids often fail
•Be familiar with indications, dose & pharmacology for vasoactive meds
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Thankyou